Side Effects Report Side Effects Report Form "*" indicates required fields Patient InformationFull Name*Age*Gender*SelectMaleFemaleWeight*PregnancySelectYesNoNo Information AvailablePhone Number*Address Do you need consulting by pharmacist?Patient History Allergy Cardiovascular Disease Diabetes Kidney Disease Liver Disease Blood Pressure History of Side Effect etc Suspected Adverse ReactionSuspected Adverse Reaction Hospitalization (Initial or prolonged) Severe and Vital Problems Physical Injury or Disability Birth Defect or Congenital Anomaly Life Threatening Death Other Items Date of ReactionYearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Description of Adverse Reaction*Suspected Medication(s)Suspected Medication(s)*Name (Brand or Generic)Bach NumberDuration of UsageIndication Add RemoveReporter InformationFull NamePhone NumberOccupation Physician Pharmacist etc Date of ReportYearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031AddressCAPTCHA
